For a small number of women, the excitement of their water breaking at the end of pregnancy is quickly dulled by the realization that there are no contractions. After waiting, and waiting, and waiting, there are still no contractions. This is called PROM, or premature rupture of membranes, which refers to the bag of water around the baby breaking before the woman’s body is ready to initiate labor. For the purposes of this article, I am only refering to women who are term, or, at least 37 weeks pregnant.
For example, a friend of mine reently had her second child. Each one of her births ended in a cesarean after PROM for more than a day, even with Pitocin augmentation and trips home to rest. Perhaps after taking apart her birth stories bit by bit we might find potential causes or solutions that may have worked to lead to vaginal birth, but the fact remains that for the few women whose water breaks and labor doesn’t begin, there is little information available from which they can gain ideas on how to handle the situation, and research on how to make safe decisions about it. And that’s where I come in.
As you anticipate the birth of your child, you should be familiar with this possibility, because it is situations like this when moms wish they knew more ahead of time so they would know what to do.
If your water breaks, your response will probably be to call your care provider. And your care provider will probably tell you to go to the hospital so they can “check you” and monitor the baby. With labor presumed to be just around the corner, you will probably react to this “doctor’s order” as exciting. You’ll pack your bag (if you haven’t already), call your partner, and drop off your older children at your mom’s. Then you’ll go straight to the hospital. If you’re birth is like many women’s you’ll begin having contractions soon after your water breaks and your birth will progress efficiently and soon you’ll be holding your baby in your arms.
But for some women, and statistically, you may be one of them, you go to the hospital only to discover that your body is not in labor, and today may not be the day afterall. Your care provider will probably order a prostaglandin cervical softener or pitocin induction. The clock is now ticking because standard protocol is that the baby must be born within 36, 24, or even 12 hours after your water breaks, for fear that infection may ensue.
But is this evidence-based care? Will you or your baby get sick if your water is broken too long before s/he is born? You may get a few quick answers from your care provider, but if you know ahead of time what to expect you’ll have much more control over how your birth is handled.
First, when a woman’s water breaks, most babies who are positioned well, will move further down into the pelvis because the water bag is no longer holding them up. This increased pressure will trigger the release of oxytocin, the labor hormone, which will initiate contractions. The time between when the water breaks and contractions begin coming in earnest is unknown. For most women whose water breaks before contractions begin, they will give birth within 24 hours. Some may not begin labor until the second day has passed, and a slight few will wait three or four days before their baby is born, but 90% will give birth within a four day period.
Women who will not give birth within a few days will obviously need help in starting their labors, but the question is, how long is it safe to wait, and is it better just to induce labor if contractions won’t come within a “reasonable” time period?
Here are some studies and reports I have found on the subject, in no particular order. Please review for yourself so that you will be fully informed:
- Cochrane Database says planned management (pitocin and antibiotics) is probably safer then expectant management (waiting for contractions)
- The British Journal of Obstetrics and Gynecology reported that women having the first baby were more likely to have a normal vaginal delivery if they were allowed to wait up to two days before administering pitocin, and when combined with no dilation checks until active labor began, there was no increased risk of infection to mother or child.
- Seaward (1998) reported that infection rates were 4% when it took 24 hours or more to begin labor, compared to 2% when inducing immediately.
- Hannah (1996) found that infections in babies and the rate of cesarean section were similar whether they waited for labor to begin or induced with oxytocin immediately, although the rate of maternal infections was higher when no pitocin was administered until four days after membrane rupture.
- The risk of chorioamnionitis with term PROM has been reported to be less than 10% and to increase to 40% after 24 hours of PROM. Am J Obstet Gynecol. Nov 1997;177(5):1024-9.
- The neonatal risks of expectant management up to four days after PROM include infection, placental abruption, fetal distress, fetal restriction deformities and pulmonary hypoplasia, and fetal/neonatal death. Fetal death does occur in approximately .01% of patients with PROM who have been expectantly managed. Clin Obstet Gynecol. Dec 1999;42(4):749-56.
- The Journal of Perinatal Medicine conducted a small clinical trial which resulted in 23% of the induced labors following PROM resulting in either cesareans or operative vaginal deliveries compared to only 10% of those who waited up to two days before inducing. They also found that those who were induced were more likely to use epidurals (41%) compared to those who waiting up to two days (24%).
- The Global Library of Women’s Medicine reported in 2008 that women with a favorable cervix (those with a Bishop score of at least 6) had little to gain by delaying labor and they should be induced, and antibiotics should be administered if labor is expected to extend beyond 18 hours. On the other hand, if their cervix was “unfavorable” or had a Bishop score lower than 6, vaginal exams should be kept to a minimum and prostaglandins should be administered until the cervix is favorable.
- In 1982, a study was published in the Journal of Reproductive Medicine that showed a significant difference in outcomes when a woman’s cervix was unfavorable: 39% of women who were induced ended up with a cesarean, compared to only 12% of those who waited for labor. There were no deaths or infections as a result of expectant management, although there were complications from the cesareans.
- A subsequent report by Duff and Colleagues, published in Obstetrics and Gynecology showed not only a significant difference in cesarean rates by management options (20% after induction, 4% after waiting), but there was also a 4x greater rate of infection among those who were induced.
- In 1989, Wagner and associates published an article in Obstetrics and Gynecology issuing a warning, saying that although they found no difference in cesarean and maternal infection rates, more babies were getting sepsis after delaying induction.
- Next came Guise in American Journal of Perinatology in 1992 which showed that maternal infection, cesareans, longer hospital stay, and infant sepsis were all more common in the induction test group.
- In 1995, Shalev published a report in Obstetrics and Gynecology which showed a significant increase in induction rates when waiting only 12 hours for labor compared to 72, although there was no big difference in cesarean, maternal infection, or neonatal infection rates. Those who were not induced (at least not immediately) stayed an average one day later in the hospital, and on this note the author recommended immediate induction following PROM for financial reasons.
Clearly this is not a black and white issue. Whether you accept an immediate induction after your water breaks, or whether you choose to delay intervention to give your body a chance, you face risks. Studies that have been done on the issue often don’t agree with each other, some saying there is no difference in outcomes between expectant and managed care, while others say there is a BIG difference. And except for one survey, none have thought to consider the psychological impact of either option. Henci Goer and Midwife Thinking are the only two places I have found reviews of the studies pointing out their major flaws, bringing into question standard protocol.
The end result is that when your doctor or midwife tells you that you must be induced because your water has broken, you must ask questions. Are you low risk? Is your baby head down and facing your back? Is your cervix soft, thin, and loose? Do you have good hygiene and nutrition? If so, waiting until labor begins may be just as safe as being induced right away. And we already know that induction carries serious risks. You need to consider both sides before you can make an informed decision.
If you decide to wait it out, here are some ways you can lower your risk of infection, and help yourself to have a better birth experience.
- Wear Depends! I know it seems so silly, but when I gave birth to my third child, my water broke right before contractions began. Wearing Depends made me much more comfortable to walk around the house and relax without worrying about leaking.
- Sleep. This is your last chance to relax before the work of labor begins.
- Do not put anything into your vagina. Your vagina is a sterile environment until something is inserted, and even sterile gloves inserted can carry bacteria from the vaginal outlet up the vaginal canal.
- If a vaginal examination is absolutely necessary sterile gloves must be used. Remember that even one cervical exam by your care provider increases your risk of infection, especially if the time between the first exam and birth exceeds 24 hours.
- Boost your immune system with vitamin C, echinacea, and garlic.
- Connect with your baby, listen to your body. Consider whether there is something bothering you that would prevent your body from starting labor.
- Tell your care provider if you are feeling at all unwell – a high temperature, a fast pulse, the amniotic fluid changes color or smell, and any reduction in the baby’s movements.
- Consider Acupuncture and Bowen Therapy, nipple and clitoral stimulation, to encourage contractions. If your cervix is ready it may be enough to kick start labor.
- Trust your body. Birth will happen.
- After your baby is born keep your baby skin-to-skin with you at all times to reduce the risk of infection.
- Make sure your baby’s heart rate is checked at least once a day to ensure that there is no cord compression.
- Remember that a low amniotic fluid index of less than 2cm is not alone an indication for immediate delivery unless other means of fetal surveillance are nonreasurring.
- Also remember that having your white blood count checked periodically to monitor for infection will not predict the outcome of your birth. It is only useful if other signs of infection require a confirmation of illness. If signs of infection are present, it will be safer to induce immediately.
- Try to confirm the baby’s position. If baby’s head is well-applied to your cervix, having the cord compressed is unlikely. If baby is high up or not head down, it may be safer to have continuous monitoring to ensure that the cord is not compressed.